billy stewart health adviser, global health partnerships team december 2005 health system...

Billy StewartHealth Adviser, Global Health Partnerships TeamDecember 2005

Health system development for equity – a

bilateral’s perspective

1 Palace Street, London SW1E 5HEAbercrombie House, Eaglesham Road, East Kilbride, Glasgow G75 8EA

About this presentation

Objective: to move closer to a coherent view which:• better links the scaling up of TB services with

the broader scaling up agenda for health, and• questions how we can apply an equity lens at

all levels

Outline • Discourse on equity• Scaling up in health – DFID analysis• Challenges to scaling up for health

• User fees• Social transfers • Global initiatives

• Role of donors – better aid• Conclusions

Why the concern with health equity? (1)

A matter of:• Economic growth - equity in human

capacities through health (& education and social protection) is key strategy to level the playing field for people to lead productive, fulfilling lives [WDR 2006; CfA 2005]

• Development and poverty reduction - equity at core of health systems is prerequisite to achieving MDGs [WB 2004, WHO 2005]

• Social justice and human rights - risk of scaling up not delivering benefits to the poor/poorest and socially excluded [WB 2004]

Why the concern with health equity? (2)

• Health system as ‘core social institution’ – can increase inequity and social exclusion, or protect citizens from poverty and discrimination [UNMP 2005]

• Recognise need to make health systems more inclusive and equitable AND to address underlying causes of health inequalities (eg. Income, nutrition, education) [WHO CoSDH]

Increasing international commitment to tackling inequities

Scaling up resources reduces trade-offs between equity and efficiency – new choices

Scaling up in Health 1: G8 commitments at Gleneagles

G8 responded to Commission for Africa recommendations by agreeing:• Comprehensive package of support – the “big push”

on peace and security, governance, health, education.• Additional $50bn globally and $25bn for Africa by

2010; • Debt relief worth up to $55bn for up to 38 of the

poorest countries, as well as $17bn for Nigeria, • Developing countries have the right to plan, sequence

and implement their own economic reforms.• Africa Partnership Forum should monitor

implementation


Scaling up in health 2: DFID Paper – Plan of Action

To turn commitment to action will require:• Increase in overall aid for health in low income

countries of $20 billion by 2010• Support to governments to develop ambitious

plans once financing commitments are clear• Donors to make progress in implementing the

Paris commitments on aid effectiveness and recommendations of the GTT on AIDS

• Donors to commit to developing and piloting mechanisms to increase the predictability of development assistance for health

• Partner countries to meet their commitments to increase funding to the social sectors

Challenges…all have an equity dimension

• Balancing targeted approaches and health system strengthening

• Increases in resources that are spent more effectively and equitably

• Responding to the health staffing crisis• Harnessing the contribution of non-state service

providers• Increasing demand and accountability• Strengthening governance• Investing in better health in fragile states• Building effective health information systems• Research into the health problems of low income

countries

Challenges: User fees - 1

• Charging poor people fees for service can be a significant barrier to access basic health care

• Removal of user fees does not equate to universal free services for all (G8 and HMT commitment)

• Removal of official user fees has less impact where:

Many other cost barriers faced by poor people Many other social-cultural, geographical barriers Dominant private sector service provision Symptom of under-investment in primary healthcare

• Also need investment in service expansion and quality

Challenges: User fees – 2

DFID policy line (2005) Yes, remove user fees…but it’s not a magic bullet:

• Support removal of official user fees for basic health care

• Help identify alternative sources of finance• Encourage removal of other fees and charges• Part of broad-based efforts to fund and

deliver quality, equitable healthcare for all (eg. Uganda)

Challenges: Cash transfers - 1

• Non-contributory, regular and predictable cash grants delivered direct to households or individuals

• Demand-side financing and social protection • Multiple objectives – reduce income poverty,

hunger & food security, child labour; improve human development; can also stimulate local markets and growth; OVC care package

• Can also provide sense of entitlement to claim citizen’s rights to access services

Challenges: Cash transfers - 2

• Cash transfers can improve human development (CfA,WB):

Equitable access to services: tackle demand side barriers beyond user fees - indirect and opportunity costs, gender discrimination

Tackle factors underlying health inequalities: malnutrition, income poverty

Target resources to poorest and socially excluded

Prevent inter-generational transmission of poverty

• Also need investment in health and education sectors to respond to scaled up demand and to improve quality

Challenges: Global Health partnerships - 1

Opportunities• Increasing within context of growing assistance in health• Targeted at the poorest countries• Support cost-effective interventions• Technical/advocacy partnerships – promote equitable

approaches

Risks• Transaction costs - multiple coordination structures• Impact on domestic resource allocation

• Introduction of high value commodities – countries running to keep up, or

• Entrenching lower levels of spending• Impact on health systems – role of community health

workers

Challenges: Global health partnerships - 2

National Health Strategy (Plan) (often limited

to public sector)

Non-public provision and care capacity

AIDS National

Action Frame

work

MultiYearImmunisationPlan

HealthWork ForcePolicy Framework

NationalTB Strategy

After: Sigrun Mogedal

• Alignment• Simplification of

coordinating mechanisms

• Coordinated health workforce policy framework

Donor financing 1 – DFID paper: making aid more effective

• Channel scaled up aid through range of instruments – where possible use flexible programmatic instruments (PRBS, sector budget support)• Better ownership and alignment to national

priorities, improved efficiency in public expenditure management, reduced transaction costs – all should impact on equity

• Marginal costs of expanding are lower than for project finance

• Broad based approach to tackling MDGs (e.g. capacity in education to train more health workers)

• Additional public spending needed will be largely recurrent costs – needs longer term predictable finance

Donor financing 2 SWAps and PRBS: Opportunities for equity (the theory)

• SWAps based on open participatory planning allow for incorporation of health needs identified by NGOs and civil society

• SWAps: Resource allocation across sector according to national needs and priorities, not on a project basis

• Improved diagnosis of barriers to service utilisation

• PRBS: “the aid instrument most likely to support a relationship between donor and developing country partners which will help to build the accountability and capacity of the state” (DFID)

Donor financing 3 – SWAps and PRBS: Risks

• Published evidence indicates limited participation of civil society (Foster, 2000)

• Little evidence that they help to resolve politically sensitive problems

• Risks of disrupted services during transition (Foster, 2000 – though rpeorted as largely anecdotal)

• Risks that health sector will not receive fair share of funds under PRBS - education received greater priority for funds under debt relief programmes (Gilson, 2005)

• PRBS – could it undermine the role of the Health Ministry by making Ministries of Finance more responsive to donors (Gilson, 2005)

• PRBS – is it actually more predictable? (DFID PRBS paper)

Donor financing 3 – SWAps and PRBS: Way forward

• Health sector not marginalised where country aligned policies and plans for pro-poor service delivery in line with PRSp (Gilson, 2005)

• Also need specific targets for health care financing and delivery and monitoring of progress and outcome indicators. Role of qualitative data

• Malawi – new relationship between NTP staff and District Health Officers – to ensure quality TB services, increased case notification, and simplified diagnostic pathways

• Establishment of Equity and Access sub group in Malawi – opportunity for lesson learning• Link to wider poverty monitoring initiatives• Analysis of existing data• Review district allocation formulae• National health accounts• Review of accountability framework

Conclusion – Making the links

• On the TB programme side• At country level: For some time experience of integration of

TB programmes – but the challenges of new programmatic tools argue for attention to lesson learning both on service delivery and on equity

• Improve alignment and complementarity of global initiatives • At global level: Continue to mainstream equity within new

Stop TB strategy – TB and poverty network• Provision of TA within overall human resource frameworks

• On the health and development side• Poverty monitoring and analysis of barriers to access –

Malawi experience• Monitoring and evaluation of outcomes – inc TB• Consideration of disease control services within sector

reviews (include TB experts?)• Broad based approaches to reaching MDG goals – e.g. social

transfers• Understanding of resource needs for TB, linkage to health

systems, fed into planning


billy stewart health adviser, global health partnerships team december 2005 health system...

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